Turf wars in the forensic setting
Subspecialising within specialty areas of medicine is necessary to ensure there is depth of experience and skills, nuanced to the very demands of the work. A hand surgeon is particularly experienced in that anatomical area, and as much as an orthopaedic surgeon has rich experience, they would refer on if the problem involved the structure and function of the hand in most situations.
According to the RANZCP, about 50% of current advanced trainees are undertaking sub specialty training, the majority undertaking child and adolescent subspecialty training. Other subspecialty areas include forensic, old age, perinatal and the psychotherapies. The remaining 50% obtain their Fellowship with the RANZCP and are deemed “General Adult” psychiatrists.
However, there is a dire shortage of psychiatrists overall, and in some areas there is no access to psychiatrists with these subspeciality set of skills and training. Many CYMHS (child and youth mental health) services cannot find a child and adolescent psychiatrist, and there are many vacancies within the forensic psychiatry setting. There are definite concerns if psychiatrists with general adult training such as myself take on this work, and it could be perceived as working beyond our scope of practice.
But in some cases, is it time to consider if there should be so much protection of turfs?
In my past clinical experience, I would see adolescents from the age of 16 years onwards, while working at a large private psychiatric hospital. I did complete a year of child and adolescent training before becoming a mother, but found the work too confronting, so I completed my psychiatry training with general adult rotations.
I remember occasions where I would see an adolescent patient in crisis and needing urgent transportation to a public hospital emergency department where they would be seen by a “proper” child and adolescent psychiatrist. I was often told by my patients later on that the psychiatrist had made derogatory comments about me, that I did not have the proper skills to manage them.
Apart from being extremely unprofessional, it also drove me away from doing the work that there are barely enough psychiatrists for. I would never see children, but I considered 16 year olds to be mini adults anyway and knowing that the onset of most adult psychiatric disorders begins about this time, I didn’t feel out of my depth. I always referred to myself as an adult psychiatrist and didn’t claim to have subspecialty qualifications in child and adolescent psychiatry. But given I did not have my colleagues support when my patients were unable to be managed by me in the private setting, I stopped.
Similar issues occur in the world of medicolegal report writing. Psychiatrists with subspecialty qualifications in forensic psychiatry have often worked as independent medical examiners. Forensic psychiatrists have particular skills and extensive training working with criminal behaviour, and issues around offending and treatment of major mental illnesses where there has been criminal or violent consequences. Traditionally they have taken on medicolegal work, because of their further understanding of the legal process.
However, what has been recognised, and especially recently is the role and value that general adult psychiatrists provide when engaged as independent medical examiners in the civil space. General adult psychiatrists have worked on Medical Panels and on individual matters for decades.
The need for expert assessments and reports for civil matters such as third party, personal injury, medical negligence and historical sexual abuse claims is never ending. As I have trained and been mentored in this area, I notice that I can bring skills to this work that a good “general psychiatrist” should possess. I am not asked about offending behaviour, and even if a claimant or plaintiff is incarcerated or has an extensive criminal history, the questions posed to me are about whether there has been a psychiatric injury as a result of some alleged abuse or injurious incident. I stay in my lane and on my turf.
I have ventured to more forensic psychiatry conferences as I continue with my professional development, and am welcomed to varying degrees, as are my civil psychiatry colleagues. The program often has some very valuable learning and insights form esteemed speakers and I tend to sit on the purely criminal based topics, sometimes just for general and academic interest.
I have just attended the RANZCP Faculty of Forensic Psychiatry Conference in Melbourne, and was really impressed by the mix of speakers, some from the forensic setting and some who are brilliant adult and general psychiatrists who had worked in the medicolegal field for decades. Their presentations reminded me about what it takes to be a good medicolegal expert, and that is to be a good general psychiatrist, with years of experience working with patients who had experienced trauma or adversity, treating them for the long haul.
When I trained I spent hours learning and mastering how to take a comprehensive history, using a “manilla folder” technique to organise my information, before I would formulate the case and the materials in front of me, and then present the “salient features of the case” to time.
A good general psychiatrist is able to do this well, and these skills are the necessary requirements for doing good medicolegal reports. An even better general psychiatrist has considerable experience working with patients for the long haul. This experience strengthens a medicolegal report, by the very nature that it is written from the perspective of a psychiatrist who understands the impacts of abuse and other adverse childhood events.
I still come across forensic psychiatrists who attempt to devalue my opinions and my reports, particularly when on opposite sides of a case. It can become a “battle of the reports” and an attempt at undermining the psychiatrist on the other side by running down their credentials is an easy way to do it. But I do stand firm that I can diagnose, offer sensible and evidence based opinions on the management required as well as provide a prognosis about recovery. I can back up my report based on my clinical experience and my academic teaching, as well as my ongoing professional development.
With the findings delivered from the Royal Commission into the Institutional Responses to Child Sexual Abuse, and the uptick of medical negligence cases arising out of the drastic conditions that health professionals had to work in during the COVID-19 pandemic, we have a workforce crisis that parallels that in our clinical setting.
People pursuing compensation claims for such matters deserve our timely attention and availability, just as our patients do. We know that protracted claims can cause harm in and of themselves, as they keep the claimant invested in the sick role, often unable to contemplate recovery, and often re-traumatised as they continue to re-tell their stories of injuries and abuse. It is not fair to ask an examinee to wait up to a year to be assessed by a psychiatrist, and the demand for our work is only increasing.
Given all of this, I do believe it is time to really examine what is required of our independent medicolegal examiners, beyond their post nominals. A qualitative analysis of our Curriculum Vitae and recognised areas of interests, as well as our clinical experience should shape relevance and currency more than having a membership to a specific Section or Faculty of a College.